Hospital medicine around the world
By Jessica Berthold
Australia and Chile are not often mentioned in the same breath. Yet these very different places have something important in common: committed health leaders who are working hard to bring hospital medicine into their countries’ medical mainstream.
In fact, hospital medicine is catching on in several countries outside the U.S., Canada and Europe, where it has existed for years. While the health care systems and situations in these nations differ, supporters’ reasons for wanting hospital medicine to flourish there are often the same—more efficiency, better patient care and better quality of life for the physicians. The barriers are often similar, as well.
“I encountered the same mix of excitement, and cultural and political resistance to hospital medicine, as we encountered here in the U.S.,” said Jeanne Huddleston, FACP, a hospitalist at the Mayo Clinic in Rochester, Minn., who has advised health leaders in New South Wales, Australia. “We just happen to be approximately 10 years into the journey.”
Changes down under
Dr. Huddleston spent a week in New South Wales in summer 2007, giving talks at quality meetings and at various hospital business and board meetings about the U.S. model of hospital medicine. She then spent June 2008 visiting eight hospitals in the province, as well as doing videoconferences for rural hospitals. While there, she worked with hospital leaders on how to translate the U.S. model into workable strategies for each hospital.
Australia’s medical system is completely socialized, but many of the quality, cost and efficiency problems are still similar to the U.S., Dr. Huddleston said.
“They are dealing with some of the same cost and length-of-stay issues. There is also room for improvement in efficiency, which having a dedicated physician on the floor, monitoring patients, would help achieve,” Dr. Huddleston said.
Traditionally in New South Wales, hospitals have had “medical officers” whose duties and role are very similar to those of the “house doctor” in the U.S. These officers work under the supervision of board-certified physicians, take call, and spend a lot of time in the emergency department, Dr. Huddleston said.
“What New South Wales is looking at doing is reclassifying this type of physician as a hospitalist—giving them some more faculty development, career development and educational development so they can function more independently,” Dr. Huddleston said. “They want to elevate the skill level for these people, to involve them with quality improvement and the day-to-day operations of a hospital.”
To achieve these goals, New South Wales wants to create an educational track for residents and other physicians who decide they want to be in hospital medicine—much as U.S. hospitalists take continuing medical education (CME) and leadership development classes, Dr. Huddleston said. The track would include coursework in measurement, guidelines, clinical care development and model development.
Unlike in the U.S., hospitalists under this system would still require supervision from board-certified physicians, she added. They also wouldn’t be allowed to do admissions.
Some specialists and primary care physicians have resisted the transition to hospital medicine in New South Wales, she said. Their main concerns are with maintaining physician autonomy and continuity of care for patients—similar to the fears some U.S. physicians once had. On the other hand, those Australian doctors who would actually become hospitalists clearly embrace the change.
“They feel they are already doing a lot of this work, and they look forward to being more engaged in the hospital,” Dr. Huddleston said.
A slow start in Chile
Half a world away, Chilean physicians have been making a go of bringing hospital medicine to their own country. Ricardo Rabagliati, MD, was a pioneer in 2005: As then-head of the internal medicine service at Hospital Clínico de la Pontificia Universidad Católica de Chile, a private hospital in Santiago, he created the country’s first known hospitalist service of three physicians.
“We were just finishing our internal medicine fellowships (at the hospital) when Dr. Rabagliati talked to us about the idea,” said Andrés Aizman, ACP Member, a hospitalist at Hospital Clínico. “He’d heard about (hospital medicine) and liked it, and it made sense to us, so we decided to do it.”
At the time, there were many specialists making rounds during their one- to two-month rotations at the hospital, but no core of physicians heavily involved with the service. As such, there was no one to really take charge of service protocols or quality improvement projects, Dr. Aizman said.
“We thought that maybe if we had a stable corps of hospitalists in here, we could give more identity to the service and start to investigate projects and research,” Dr. Aizman said. “We wanted to get some kind of quality and safety culture in our service.”
Mission accomplished. Dr. Aizman’s intermediate care unit now has four hospitalists, and they are working on protocols for DVT prophylaxis, glycemic management, stress ulcer prophylaxis, pneumonia management and medication errors. They are also in the midst of running a government-funded randomized trial to test new insulin protocols. Soon, they will hire two more hospitalists, bringing the number on the service to six.
Patients and their families seem to like the change: Satisfaction scores on patient surveys have improved in the last two years, Dr. Aizman said.
“The patients like that we are around more during the day, and the families like that they can talk to us more easily,” he said.
The idea seems to be spreading to other hospitals in the city and region, Dr. Aizman added. He and his hospitalist colleagues have been asked to speak at medical meetings, and have been contacted by two or three hospitals in Santiago for more information. They held their first Chilean meeting about hospital medicine in November 2008, which nearly 300 people attended, and another is planned for next year.
Some systemic barriers to hospital medicine exist in Chile, however. While Dr. Aizman’s hospital is private, about 70% of those in the country are public. Physicians at public hospitals aren’t generally paid well, so they tend to work only a few hours doing rounds in these hospitals, then go to work in the private system. That doesn’t give anyone much incentive to make working in a public hospital a full-time career, Dr. Aizman said.
The second barrier to hospital medicine catching on is that there isn’t much incentive to make hospitals run more efficiently and economically, he said.
“In the U.S., you get paid per code, so if you make the work cheaper or more efficient—like if people stay for fewer days in the hospital—you can make more money in the end,” Dr. Aizman said. “The insurance companies don’t have that kind of system around here.”
Baby steps in Brazil
In Brazil, too, physicians are poorly paid and often work several jobs at different hospitals and clinics, which makes it difficult for hospital medicine programs to gain traction, said Guilherme Barcellos, MD, a champion of hospital medicine in that country.
“Because they have several jobs, it’s difficult for physicians to find time to focus on professional activities, much less focus on inpatient care at a single institution,” Dr. Barcellos said.
Guilherme Barcellos, MD, addresses attendees at the first meeting of the Brazilian Society of Hospital Medicine.
Yet hospital medicine is gaining a foothold nonetheless, in no small part due to the efforts of Dr. Barcellos and his internal medicine colleagues at Nossa Senhora da Conceiç&ão Hospital (HNSC), a public hospital in Porto Alegre, Brazil. Together, they started a program in 2005 that trains third-year residents of HNSC’s internal medicine service in hospital medicine—the first such program in the country to do so, Dr. Barcellos said.
They also established a society in 2004 called GEAMH (Group of Studies and Update in Hospital Medicine), to promote the understanding of hospitalist principles in the region and country. This eventually morphed, in 2008, into the Brazilian Society of Hospital Medicine, which held its first meeting in May of that year.
“This was the first organized attempt to gather together the key players who are individually trying to improve hospital care in Brazil through the hospitalist model,” Dr. Barcellos said. “We had about 600 attendees, including physicians, nurses, hospital administrators and medical students, as well as members of the Brazilian Ministry of Health.”
A unique problem faced by hospital medicine proponents in Brazil is that some organizations are using the term “hospitalists” to refer to intensivists on rapid response teams, Dr. Barcellos said.
“Other hospitals have hired doctors to be part of rapid response teams from the wards, but their patients are still being admitted in the traditional model of care. We need to clearly separate this from the hospitalist model,” Dr. Barcellos said.
At present, there are about six hospital medicine programs in Brazil, with another six in development, he said. The path for these hospitals hasn’t always been easy. When Dr. Barcellos tried to create a patient safety course for the third-year hospital medicine residents he teaches, for example, his effort was stifled.
“I was told by an important person that to say that care needs to be safe is to admit that it isn’t always safe currently, and that’s not good,” Dr. Barcellos said.
There is also pushback from some outpatient doctors who fear hospitalists will steal their patients, he added. In time, Dr. Barcellos said, he hopes these doctors will realize they can work much more efficiently in their outpatient settings if they don’t have to go to the hospital every day.
“Many in the medical community view hospital medicine with alarm and suspicion,” Dr. Barcellos said. “You have to work gradually to change the culture and show that everyone can win.”
Argentina: Planting the seeds
While there are a few hospitals that have full-time physicians taking care of patients, hospital medicine doesn’t officially exist as a discipline in Argentina, said Esteban Gandara, MD, a clinical research fellow in internal medicine at Harvard Medical School and a native Argentinian who is helping to bring hospital medicine to that country.
Dr. Gandara said that hospital medicine could potentially appeal to younger physicians, who are increasingly put off by the stigma attached to general internal medicine.
“Being a general internist in Argentina can be diminishing; people don’t admit you are trained and just call you a clinician,” Dr. Gandara said. “Hospital medicine is a way to make a name for yourself and practice internal medicine without having to get into a clinical specialty.”
At Hospital Universitario Austral in Pilar, where Dr. Gandara used to work, the seeds of hospital medicine have been sown. For the past year or so, one group of physicians has been devoted entirely to inpatient work, and another to outpatient.
“Before this, we implemented comanagement of diseases for surgical patients, and this seemed like the next logical step,” Dr. Gandara said. “So far, the doctors really seem to like it.”
It will take time before the majority of Argentine physicians come to view hospital medicine as its own distinct discipline, however. In part, this is because of a misperception as to what hospital medicine means, Dr. Gandara said.
“If you ask most physicians in Argentina, they are going to tell you they are hospitalists because they spend a lot of time seeing patients at the hospital. Their outpatient clinics are at the hospital, and they have their assigned beds in the hospital,” Dr. Gandara said.
To get things moving further, Dr. Gandara hopes to use Brazil as a mentor, he added.
“Brazil is having a meeting next year, and I am trying to network with people in Argentina to go to it. Their health system is very similar to ours, so I think getting on board with Brazil is going to save us time and get us on track,” Dr. Gandara said.
Cultivating hospitalists in Colombia
As in Argentina, hospital medicine is largely unknown in Colombia. But a few committed champions are looking to change that.
With the help of Jairo Roa, FACP; Fernando Rivera, FACP, and James S. Newman, FACP, the country held its first hospital medicine meeting Feb. 26 in Bogotá. Dr. Roa is professor of medicine at the Universidad de Los Andes and Jefe Departamento de Medicina Interna, Fundación Santa Fe de Bogotá; Dr. Rivera is senior associate consultant and instructor of medicine at the Mayo Clinic in Rochester, Minn.; and Dr. Newman is a Mayo Clinic hospitalist (and ACP Hospitalist’s editorial advisor).
At the conference, guest speakers from the Mayo Clinic led sessions for more than 400 hospital administrators and providers on topics like hospital throughput, specialty units and hospital-acquired infections.
While some Colombian hospitals already have practices that are similar to hospital medicine services in the U.S.—with physicians doing strictly inpatient work—they aren’t well-organized, Dr. Roa said.
“Our plan for the future is to help these hospitals organize their hospitalist services—to teach them how to run their service well, and to increase patient safety,” Dr. Roa said. “Eventually, we hope to start teaching hospital medicine in medical school, as well.”
Physicians from several countries have combined forces to help promote the ideas and practice of hospital medicine in the western hemisphere through the newly created Pan-American Society of Hospitalists (PASHA). The group will focus particular attention on hospital medicine issues that are most important in South America, and will hold its first meeting in Florianopolis, Brazil, in late November 2010. Internists from Brazil, Colombia, Chile, Argentina and the U.S. will comprise PASHA’s initial leaders.
“The basic idea is to have meetings in different countries in South America, with a local university sponsor, and to bring speakers down from the U.S., where hospital medicine is in its more advanced stages,” said James S. Newman, FACP, a Mayo Clinic hospitalist, co-founder of PASHA, and ACP Hospitalist’s editorial advisor. “The speakers will talk about the advantages of hospital medicine, how to start a program, as well as clinically related themes like quality and best practices.”
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